Book reviews

The need for a modern biography of James Buchanan is admirably met in this thorough and scholarly, yet eminently readable, book. Professor Klein has done more than ransack the sources and weave a great mass of detail into a clear, lively narrative. He has rescued a remarkable and much-abused statesman from the shadowland of caricature. Buchanan's is not an easy character to delineate. He was a convivial man and yet a lonely one. The only bachelor president in American history, but by no means a confirmed celibate, he shied away again and again from the intimacy of marriage. To a host of relatives whom he took under his wing, he was both generous patron and snoopy tyrant. In politics, although actually somewhat doctrinaire, he earned the reputation of being a trimmer. He preferred to work toward compromise and consensus, but at times a deep streak of stubbornness blinded him to realities. He was a Jacksonian who had been a Federalist, a democrat with aristocratic manners and social views, a politician with no great liking for controversy. Far better trained for the presidency than most occupants of the White House, he is nevertheless usually listed among the failures in that office. In short, both as a person and as a public figure, Buchanan is something of an enigma. Klein's study, without answering all questions, certainly makes him much more understandable. Contrary to what the title might lead one to expect, considerably more than half the book is quite properly devoted to Buchanan's pre-presidential years, which, after all, numbered a full sixty-five. Beginning with election to the state legislature in 1814, his political career included five terms as congressman, ten years in the Senate, four years as Polk's Secretary of State, and two sojourns abroad as minister to Russia and to Great Britain. In addition, he was continually involved in Pennsylvania politics, and here Klein's masterful knowledge of state history lends added authority to his writing. The younger, less familiar Buchanan of the 1830's and 1840's, although not cast in the heroic mold of a Webster or Jackson, nevertheless emerges as something more than a wily opportunist, indeed as a man of substantial talent, force, and intellect. Why, then, did his presidential administration end in disaster for his party and his country? A partial answer, suggested by Roy F. Nichols, is that Buchanan became chief executive when he had passed the peak of his powers and when the nation had

theory or practice; to reprehend what we conceived to be erroneous in either, so that the profession at large, and the junior part of it in particular, should not be misled by false doctrines sanctioned by high authority: nor should the good be passed by, because it presented itself to us in an unassuming, or perhaps even in an homely, garb. -Upon all occasions we have endeavoured to separate the author from his work: the latter is public property, the former is sacred: the work may, if faulty, i>e productive of incalculable mischief, and must be exposed; our duty to our readers demands it, and, as far as our judgment and abilities permit, this object it shall always be our aim to accomplish. This intellectual dissection we will endeavour to perform in as cleanly and decent a manner as we can; for, in this, as in other dissections, the design is not to expose the subject, but to instruct the lookers on. J-i__ From this short digression we turn to the splendid; work before us; in bulk, in beauty of paper and type, in the number of plates, and,in the excellence of their (execution,, surpassing any modern publication on a professional subject with which we no. 288. t 13'2 Critical Analysis. are acquainted,?at least in this country. On turning over the pages of this book, we were at first tempted to exclaim against the numerous errata of the press which we encountered on every side; but, when we began the perusal seriatim, we were so struck with the author's candid avowal of this error, that we were induced to strike out the reprehension which this unlucky discovery had elicited. However, we must notice particularly one of these errata in this place, because it is not corrected, and it directly affects the sense of the passage: it occurs in page 338, and will be more particularly pointed out in its place. Our experienced author also endeavours to obviate any objection that may be raised against the familiar and occasionally colloquial style of the work; declaring " that he had rather be seen in a good plain suit, than in the finest embroidered dress.'* (Preface, p. vii.) It is, however, to be recoliected that a certain attention to dress is necessary to obtain admission into the best society; and (dropping the metaphor) that, as this volume is intended to go down to posterity, and will most assuredly do so, the style is a matter of more importance than in those ephemeral publications which are born only to die.
Many may consider these preliminary remarks, perhaps, as rather fastidious; but let them recollect that Sir Astley Cooper is likely to be quoted as an authority, and followed as an example; and, therefore, it behoves us more especially to notice those points in which he has failed, lest they should be adopted by others who do not possess his eminent and redeeming merits.
We have but one more remark to make before we enter upon the analysis of the work, and that remark relates to the price at which this book has been published certainly a very noble instance of liberality on the part of the author, but which must not lead us to form unfair conclusions with respect to other authors less fortunately circumstanced, and who have it not in their power, whatever their wishes might suggest, to follow this splendid example.
The bulk of this volume consists of a reprint of the Essays on Dislocation, published in the octavo edition, with some additional matter": the plates, however, are new, and increased both in number and size, as well as in beauty of execution. Sir Astley Cooper informs those who are in possession of the former edition, that, for their convenience, he will print the additional matter in the octavo form, provided they express their wishes and send their names and address to him, within three months after this publication.
Sir A. Cooper commences his work with remarks on dislocations in general, and almost immediately details an interview which a patient, whose shoulder had been dislocated " many Sir Astley Cooper's Treatise on Dislocations. 133 weeks," bad with him. It appears that the surgeon tn the country had mistaken the nature of the accident; and our author's advice to the patient was, not to suffer any attempt at reduction. We do not in the least doubt that Sir A. Cooper s advice was highly judicious; but he seems to anticipate, in his preface, that his professional brethren may imagine that he has limited the period at which reduction may be attempted too strictly : and, with respect to dislocations of the shoulder, there is some reason to think that he has. " A considerable share of anatomical knowledge" (we quote Sir Astley's words,) " is required to detect the nature of these accidents, as well as to suggest the best means of reduction ; and it is much to be lamented that students neglect to inform themselves sufficiently of the structure of the joints. They often dissect the muscles of a limb with great neatness and minuteness, and then throw it away ?without any examination of the ligaments ; a knowledge of which, in a surgical point of view, is of infinitely greater importance." We have printed this very important remark in italics, in order to call the particular attention of our younger readers to it, fully agreeing with our author, both in the truth of his remark, and great importance of impressing it strongly on the minds of all classes of students in our profession.
Yet, with the most accurate knowledge of the structure of the joints, the tumefaction and tension arising from the injury occasionally so obscure the nature of the accident as to render it extremely difficult to be detected ; therefore, conclusions drawn when the swelling has subsided, the muscles are wasted, and the head of the bone can be distinctly felt, would be both illiberal and unjust." The immediate effect of a dislocation is to alter the form of the joint; often to produce a change in the length of the limb, to occasion the almost entire loss of motion, and to alter the axis of the limb. In the first moments of the dislocation, it is to be remembered that considerable motion remains. In a case at Guy's Hospital, where the thigh was dislocated into the foramen ovale, a great degree of mobility of the bone existed at the dislocated part, but in less than three hours it became firmly fixed in its new situation by the permanent contraction of the muscles. This is very important to remember, because mobility of the bone is one of the most marked symptoms of a fracture of its neck, though in this case the knee is turned outwards. After describing the usual criteria by which dislocations are known, Sir Astley observes that, among the more remote effects of these accidents, the crepitus produced by the effusion of .adhesive matter into the joint and bursse, may induce the practitioner, if lie bo not aware of it, to suspect a fracture where none has occurred, Inflammation of the joint occasionally is 134 ' * \ Critical Analysis, also so severe as to produce suppuration, and to destroy the patient, even after the reduction of the dislocation; and two cases of fatal result are mentioned, (p. 7.) We believe this seldom occurs, except in dislocations of the thigh. Sir Astley's description of the dissection of dislocated joints is, of course, accurate; but, as it presents no novelty, we pass on to observe, that dislocation sometimes arises merely from a relaxation of the ligaments of thejoints, of which three instances are inserted, where the patella was dislocated in that manner.
Relaxation or paralysis of the muscles will also sometimes produce the same effect; but these accidents may be considered as comparatively rare.
It is well known that the hip-joint frequently becomes dislocated in consequence of ulceration. Sir Astley Cooper mentions a preparation, now at St. Thomas's Hospital, where the knee was dislocated by ulceration ; and a case of the same kind occurred in a boy, a patient at Guy's Hospital.
Dislocation accompanied with fracture is a common occurrence at the ankle-joint. At the hip-joint, the acetabulum is occasionally broken off. The head of the humerus, and the coronoid process of the ulna, also may experience the same fate.
In the event of a fracture and dislocation occurring at the same time, our author advises the dislocation to be reduced before the fracture be adjusted, and confirms his opinion by the case of a gentleman who had his leg broken and his shoulder dislocated: the latter.* was not attempted to be reduced until a fortnight after the accident, and then the attempt failed, the fractured leg prohibiting the employment of the necessary degree of force.

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: ; A compound dislocation is next defined, its essence consisting in the exposure of the cavity of the joint, in addition to the displacement of the articulatory surfaces : of course, the effect is an extravasation of blood into the joint, and the escape of the synovia, (p. 18.) We need hardly add, that these accidents are declared by our author to be attended with great danger.
In "explaining the causes of this danger, Sir Astley says, " When a joint is opened, inflammation of the lacerated ligaments and synovial membrane speedily succeeds; in a lew hours suppuration begins, and granulations arise from the synovial membrane, which, being a mucous membrane, is more disposed to the suppurative than to the adhesive inflammation." Here Ave humbly conceive there is a slight pathological error : ?we always regarded the essential characteristic of a mucous membrane to be, one which communicated with some external opening of the body ; and we have been taught to consider the synovial membranes as a class by themselves. The leading circumstances that render this species ot dislocation so serious are Sir Astley Cooper's Treatise on Dislocations. 135 then described ; but the mode of treatment is deferred until the compound dislocations of the ankle are described,.." wneie ley will be better understood ; and thus a repetition, whic \ vv.o ^ be both irksome and useless to the reader, will be avouie t (P* 19?) , ' u On the causes of dislocation, our author observes, that, when the muscles are unprepared for resistances, very slight accidents will often bring about the effect* A fall in walking will sometimes dislocate the hip-joint, when the muscles have been prepared for a different exertion.
Dislocations of the elbow-joint in children, Sir Astley thinks to be rare; such cases usually being, in reality, fractures of the condyles of the os humeri, which assume the appearance of dislocation in consequence of the radius and ulna being drawn back with the fractured condyle.
In enumerating the circumstances that impede reduction, our learned author mentions the form of particular bones, or the cavity that receives them, may in part occasion the difficulty. He very judiciously combats the supposition that the capsular ligaments resist reduction ; neither do they appear to have any power in preventing the occurrence of the dislocation: it is the ligaments peculiar to the joints, and the tendons spread over them, that form the principal obstacles to the displacement of bones, and the resistance of the muscles which is the most formidable pbstacle to their re-adjustment. When a bone has been a long time displaced, the extremity also contracts adhesions to the surrounding parts. Sometimes also the socket of the bone becomes filled with adhesive matter; and, " lastly, a new bony socket is sometimes formed, in which the head of the bone is so completely confined that nothing but its fracture could allow it to escape from its new situation." (p. ?9-) The means of reduction are divided by our author into constitutional and mechanical: the former are principally three,?r bleeding, warm-bath, and nausea. Of these, Sir Astley considers bleeding the most powerful; and the operation should be performed in the erect position, in order that syncope may the more speedily be induced: an opinion in which we entirely concur, and which we are surprised to find so often mentioned by different professional men, and yet so seldom practised.
The warm-bath is next recommended, the method of using which is sufficiently known ; and the third plan is that of exciting nausea, by means of tartarized antimony in small doses, which however will seldom succeed alone, as the operation of that medicine is so very uncertain and. dissimilar in different individuals; and it becomes a matter of great difficulty to obtain the exact effect that we wish to produce. Our author, there-fore, is induced to employ it chiefly to keep up the state of syncope already produced by either of the former methods.
In describing the mechanical means, it is observed that force must only be gradually employed; an excellent rule, too often neglected: forf violent force most assuredly calls " up all the powers of resistance to oppose the efforts making by the surgeon/' The next precept is also of the highest importance: it impresses upon the surgeon the necessity of fixing the bone in which the socket is placed ; a point which Mr. Bromfield has most ably stated and illustrated in his surgical works.
In dislocations of the hip-joint, pullies should always be employed ; as also in those of the shoulder which have long remained unreduced. In attempting reduction, a relaxation of the principal muscles of the limb must be obtained by such a position as will best effect that object.
The following rule is also important, and concludes this branch of the subject: " Great advantage is derived in the reduction of dislocations from attending to the patient's mind; the muscles opposing the efforts of the surgeon, by acting in obedience to the will, may have that action suspended, by directing the mind to other muscles." (p. 34.) Sir Astley concludes these general remarks by giving it as his opinion, that attempts at the reduction of the shoulder should not be made later than three months after the accident, and for that of the hip not after eight weeks: at the same time he is aware that the shoulder hus been reduced at a much later period, though without any improvement to the patient, as far as the use of the limb was concerned.
We come now to the consideration of particular dislocations, and first in order is dislocation of the Hip-joint. This bone may be displaced in four different ways: 1st, upwards, or on the dorsum of the ilium ; 2dly, downwards, or into the foramen ovale; 3d, backwards and upwards, or into the ischiatic notch; and 4thly, forwards and upwards, or upon the body of the pubes.
The dislocation upwards is the most common of these accidents : in this case, the limb is shorter, the knee and foot are turned inwardsy the thigh cannot be separated from the other; the head of the bone may sometimes be perceived moving upon the dorsum of the ilium ; the trochanter is less prominent, and the roundness of the hip is lessened, compared with the opposite side. In order that the surgeon may not confound this accident with the fracture of the neck of the bone, he must recollect that, in this latter case, the knee and foot are generally turned outwards, the trochanter is drawn upwards, the thigh can be Sir Astley Cooper's Treatise on Dislocations. K57 bent towards the abdomen, and the limb, though shortened, can, by a little extension, be rendered of the same length as the sound one; sometimes also, in rotating the limb, a crepitus can be felt. This fracture (within the capsular ligament,) also seldom occurs but in aged subjects. In the dislocation upwards, the glutei and triceps muscles principally resist reduction.
In the description of the method of reduction, the leading points insisted upon are the gradual extension, the gentle rot? tion of the knee and foot, when the extension has been carri-^d far enough ; and the necessity that sometimes occurs of lifting the head of the bone over the lip of the acetabulum, which may be effected by placing an arm under the limb, near the joint, or by a napkin placed under it, and raised by an assistant. It is needless to add, that the extension in these cases must be made by means of pulleys, and the constitutional meaus recommended above must be previously employed. Thirteen cases are subjoined to illustrate the precepts above mentioned. It is to be observed, that, in many cases, particularly those of long standing, the bone returns into its socket without any snapping noise.
On the dislocation downwards.?This happens when the thighs are widely separated. In contradiction to what is usually said, Sir Astley Cooper asserts that, in this accident, the ligamentum seres is torn through ; the thighs, and consequently that ligament, being upon the stretch at the time of its occurrence.
The limb is shorter than the other in these cases. In very thin persons, the head of the bone may be felt upon the inner and upper part of the thigh towards the perinseum; the body is bent forwards; if the body be erect, the knee is considerably advanced ; it is widely separated from the other. rlhe foot is not generally turned either outwards or inwards, though in this respect it varies a little ; and, finally, there is a hollow below Poupart's ligament.
The reduction of this accident is, says our author, very easily effected. If it has happened recently, place the patient on his* back, separate the thighs as much as possible, and fix the body by placing a girth between the pudendum and upper part of the thigh, fixing it to a staple in the wall. The surgeon then puts his hand upon the ankle of the dislocated side, and draws it over the sound leg, and the head of the bone slips into the socket, (p. (ft.) This plan, however, will not succeed if the dislocation has existed two or three weeks : in that case the pulleys are required ; the thigh is to be drawn upwards, whilst the knee and foot are pressed down, to prevent the lower part of the limb being drawn with the thigh-bone. Great care must be taken not to advance the leg in any considerable degree, or the head of the thigh-bone may be forced into the ischiatic notch. bone on the other, which is increased by the effusion of an additional quantity of fluid within the capsular ligament. But the third reason is, perhaps, the most conclusive of all ; and that is, the little action in the head of the thigh-bone when separated from its cervix, its life being then solely supported by the hgamentum teres. In describing the dissection of these cases, We find Sir Astley more than once using the term " serous synovia," to express a thinner species of that fluid than is commonly met with. We have already ventured to protest against the synovial membrane being called a mucous one, and therefore we were grieved to perceive that our author, in this place, has very nearly called it a serous one. We are partial to precision in language, and therefore have presumed to notice this additional instance of inadvertence and haste.
Having described the appearances on dissection, our author gives us the result of some experiments on rabbits and dogs, in which he contrived to fracture their thigh-bones within the capsular ligament, and they all confirm the opinion previously delivered ; the whole evidence fully establishing, in our mitld, the point which Sir Astley has undertaken to prove.
In describing the treatment of this fracture, our author mentions several contrivances that have been adopted, all with the intention of keeping the limb fully extended: the double inclined plane; the plan of suspending a weight to the foot of the fractured side, at the same time taking measures to prevent the body descending in the bed ^ the extension of both legs, and fastening them securely together at the ankle; and the splint of Boyer, are all mentioned; and, finally, apian recommended by Mr. Hagedorn is detailed, which Sir Astley mentions as ingenious, but which he thinks will not prevent a displacement of the bone on every motion which the patient is constrained to make for the purpose of evacuating the faeces : he nevertheless, in the spirit of candour that pervades his whole work, recommends a fair trial to be given to it. After all, however, Sir Astley concludes, that all the means he has seen used have proved unavailing. ti I have been baffled," he says, he says, that in neither of these rare cases will the limb exhibit the shortened state, which the fracture of the neck of the bone usually produces, (p. 143.) There is surely some discrepancy between this last sentence and the preceding paragraphs ; for, if union might be produced in these two instances, the shortened state of the fractured limb is the only criterion by which that may certainly be known, and which usually (it is not said invariably) takes place, we cannot be justified in neglecting to make the attempt, for a length of time at least sufficient to ensure success, under the possibility of either of the above-mentioned conditions of fracture having existed. " The surgeon," says our author, " must be very careful of the opinion which he gives of the result of these cases. Lameness, in the transverse fracture, is sure to follow j but its degree cannot, at first, be exactly estimated." (p. 144.) It appears that the dissections of several cases of these fractures by Mr. Collis, [Colles,] of Dublin, fully confirm these opinions.
Of fracture of the neck of the thigh-bone without the capsular ligament we shall merely observe, that ossific union may in these cases be expected ; and several are detailed, together with the appearances of the bone and joint on dissection. In the treatment of th6se fractures, the limb is kept in an extended position most perfectly by binding it firmly round the ankle to the sound one, which thus becomes the splint to the fractured bone. Various modifications of the double inclined plane have also been employed with success in similar cases, but want of room forbids us to enter into a more minute description of the apparatus.
The fracture through the trochanter major may take place obliquely, without the cervix femoris being at all concerned. The altered position of the trochanter major, and the crepitus upon moving the limb, are the distinguishing marks of this accident, in which ossific union takes place very firmly and quickly. From the detail of the long case communicated by Mr. Harris, of Reading, we find that the fracture of the great trochanter may take place without producing either eversion or inversion of the foot, or shortening of the limb; that the crepitus may also at first remain unnoticed; and that the pain in moving the limb (except across the sound one,) may be but slight. We must here take occasion to observe, that we are sorry that this case had not been curtailed prior to publication : it contains some passages which we do not quite like, and which, however unexceptionable in a private letter from Mr. Harris to Sir Astley Cooper, leave an unpleasant impression upon our minds, which we cannot well express, but which we are confident the attentive reader will understand.
Of fracture just below the trochanter we shall only obierve, Sir Astley Cooper's Treatise on Dislocations. 143 first, that, if ill-treated, great deformity ensues from the overlapping of the bones, in consequence of the contraction of the iliacus internus and psoas muscles ; and that, consequently, the mode of preventing this deformity is to elevate the knee very much over the double inclined plane, and to place the patient nearly in a sitting position: the reasons for which mode of treatment the anatomist will immediately understand and appreciate.
We shall now proceed to the discussion of the chapter on Dislocations of the Ankle-joint, which, on many accounts, we consider one of the most important in the whole work: to arrive at this point, we have passed over upwards of fifty pages rich with a variety of matter on dislocations and fractures of the Knee-joint, Patella, &c. ; but, besides that our space is too limited to enter into the consideration of each of these subjects individually, we did not encounter any thing in that portion of the work which called for our especial notice. It must be read, ?it should be studied by the young surgeon, for it is rich in facts, and full of practical wisdom.
On Dislocations of the Ankle-joint.?A concise anatomical description of this joint, together with its ligaments, leads to an enumeration of the different directions in which dislocation may occur in the ankle; three of which only our author has seen, namely, inwards, forwards, and outwards. It is said sometimes to be dislocated backwards; and it has also been thrown upwards between the tibia and fibula. Simple dislocation of the tibia inwards is often connected with fracture of the lower end of the tibia and fibula. In order to distinguish this latter fracture, the leg must be grasped by the hand just above the ankle, and the foot must be freely rotated. In effecting the reduction, let the patient be placed upon the injured side ; the leg is to be bent, to relax the muscles; extension made with the foot, in a line with the leg; the surgeon then fixes the thigh, and presses the tibia downwards. Let the leg then be kept on its side in the bent position, with the foot well supported, and a many-tailed bandage applied to keep the parts in their places ; two splints, each having a foot-piece, should then be placed on the leg. In the event of inflammation, the usual local and general means of subduing it must be had recourse to. In five or six weeks, the patient may be moved from his bed, and put on crutches; but a much longer time will elapse before he regains the perfect motion of the foot.
We shall pass by the simple dislocation of the tibia forwards, a case by no means unfrequent, in order to notice a partial dislocation of the same kind, which is more rare: in this case, the bone rests half on the os naviculare and half on the astragalus ; the fibula is broken ; the foot appears but little shortened, nor 14^ Critical Analysis. is there any great projection of the heel. The diagnostic signs are the following : the foot is pointed downwards, and a difficulty is felt in attempting to put it flat to the ground ; the heel is drawn up, and the foot is in a great degree immoveable. In a case of this kind, it appears that our author was baffled in his attempts at reduction; and he warns us, in all similar cases, not to rest satisfied until the foot be returned to its natural position, however slight the deviation may at first appear to be. The reduction is effected by the same means as are employed in the complete dislocation forwards.
The luxation of the tibia outwards is the most dangerous of the three; for, in this case, the malleolus internus is obliquelyfractured and separated from the bone; the astragalus is also sometimes fractured, and the lower extremity of the fibula is broken into several splinters. In this accident, the proper ligaments of the joints remain untorn, if the fibula is broken ; but, if not, they are ruptured; the capsular ligament is torn at its outer part. Reduction is effected " by placing the patient on his back; the thigh is bent at right angles with the body, and the leg at right angles with the thigh ; the thigh is then grasped under the ham by one assistant, and the foot by another, whilst the surgeon presses the tibia inwards towards the astragalus." (p. 248.) The position of the limb is to be the same as in simple dislocation. The greatest care must be taken to prevent the foot from being twisted inwards or pointed downwards; and, for this purpose, two splints, with a foot-piece to each and padded, must be applied to the ankle on the outer side of the leg.
The severity of this accident calls for more vigorous measures with regard to depletion, as inflammation to a considerable extent may usually be expected to follow its infliction.
Of compound Dislocations of the Ankle-joint.?We have already said that, in our estimation, this chapter is the most important one in the whole volume, since it involves a point of practice that has been long and warmly contested, and upon which it is very difficult to speak without saying too little or too much. We nave read it over carefully again and again, and we confess the impression that it has left in favour of making the attempt to save the limb in these accidents is stronger than, upon reflection, our calm reason and sober judgment can approve. We do not in the least doubt that Sir Astley Cooper himself is perfectly master of all the niceties of each possible case, and that he would decide most judiciously upon any contingency that might arise; but we do not think that he has been altogether happy in placing his subject in a clear point of view, or in dwelling upon those peculiar features of the accident that so often render amputation absolutely necessary ; and we should fear that the young surgeon, from the perusal of this chapter, Sir Astley Cooper's Treatise on Dislocations. 145 would be led to the almost indiscriminate attempt to save compound dislocations, the encouragement to save so much overbalancing the warning of danger; a mode of. practice which we are confident our experienced author had no intention of lecommending, without considerable limitation and restriction. Indeed, these limitations are mentioned; but they appear to " halt in the rear" of so many brilliant and extraordinary instances of success, as to be likely altogether to escape the notice of the young and the sanguine. It may be, indeed, that our author thought the young surgeon wanted no spur to perform an operation ; and that, therefore, he has made the possibility of dispensing with the knife more prominent than he would otherwise have done.
The first general remark suggested by the perusal of this chapter, is that the whole of the successful cases which he has detailed include nearly every one of the circumstances which lie afterwards asserts to be separately a substantial reason for amputation : thus, in one we have extensive suppurations;* in another, great deformity of the foot in a third, an extensive lacerated wound and finally, in a fourth, both an advanced period of life and an irVitable habit of body.? The sixteen cases which are published from the correspondence of a number of medical practitioners, in various parts of England, and the nine cases occurring either in his own practice or those of his immediate pupils, have too much the air of being select cases.
It is to be observed, that almost all these accidents occurred in young and healthy subjects^ with the exception of three; that TV* nnr?
*-U of these reflections, which ought to precede the decision of the question, become in the event prominent, when that event has been fortunate; but how many instances of failure are passed by ? how many cases, fatal in their result, but most instructive to the living, are omitted? and which, from their very failure, become interesting, as they tend at once to clear up the difficulty which surrounds this important and much-disputed point.
Let us now leave these general remarks, and resume our analytical labours.
The immediate consequences of the compound dislocation of the ankle-joint, is the exposure of its cavity and the escape of the synovia; inflammation soon becomes established, in which the extremities of the bones and ligaments are equally involved, and suppuration ensues in about five days. Under this process the cartilages become wholly or partially absorbed. This process is attended with severe constitutional irritation, and often lays the foundation for exfoliation of the bones. The granulations arise from the surfaces of the bones and the inner side of the ligament, and thus the intervening cavity becomes filled.
Sometimes, says our author, the adhesive process occurs at one part, and the cartilage is not absorbed ; whilst granulations are formed at others, where the cartilage was removed by ulceration; and he has seen, after inflammation in the joints, the cartilages remain, and their surfaces adhere, (p. 251.) But permanent anchylosis does not necessarily ensue; for, by employing passive motion as soon as the inflammation has subsided, some degree of motion will be restored : sometimes, indeed, this deficiency in the mobility of the joint is but little apparent. The following circumstances then occur, as necessary consequences of this accident: an extensive suppuration over the joint, with great constitutional derangement; then an ulcerative process, more or Jess extensive, by which irritative fever is kept up for a great length of time ; and sometimes, in consequence of ulceration extending to the extremities of the bones, an additional constitutional irritation, and protracted disease from exfoliation. After some further discussion upon the causes of the symptoms, cur author then proposes his principal question ?" Is amputation generally necessary in compound dislocations of the ankle?" His answer is, certainly not. Now, let us contrast this opinion with the following reasons, that he himself declares will give rise to a necessity for amputation in these cases, and then we shall see that this decided negative must be received with much reservation; and that the young surgeon must weigh eve-y one of these circumstances well in his mind, together with all the local and individual peculiarities of the patient, before he can fairly appreciate the force of the precept, which, we do not hesitate to repeat, is both urged too forcibly, % Sir Astley Cooper's Treatise on Dislocations. 147 and put in a point of view much too prominent and encouraging-. The reasons in favour of imputation are?-1st, a very extensive lacerated wound ; 2dly, the bones being very much shattered ; 3dly, it sometimes happens that, when the bone is replaced, it will not remain in its situation, and all the symptoms of the injury become removed, (renezaed is undoubtedly the word intended to be employed, and without which the sentence is unintelligible;) 4th, mortification of the foot; 5th, excessive contusion; 6th, extensive suppuration; 7th, exfoliations of the bone, which, being locked into the surrounding parts of bone, cannot be separated ; 8th, excessive deformity of the foot; and, lastly, an irritable state of the constitution.
In the first nine cases recorded by our author, the patients were all in the vigour of life, none exceeding the age of fortyeight. The tenth case is that of an aged man (seventy), intemperate and gouty : the accident was of the worst kind ; the articulating surfaces filled with blood and sand, the end of the bone covered with dirt, the man having got up and endeavoured to stand after the accident, and the foot completely turned outwards : in this state he was removed four miles to his residence.
This limb was saved, in consequence of the man's refusing to submit to amputation. The case was, within a twelvemonth, brought to so successful a termination, that by the end of that time he could walk without a stick. The remaining cases, with one exception, all relate to young persons; and we pass over the particulars of their treatment, because we shall presently detail the plan recommended by our author to be adopted when .it is determined to attempt saving the limb, as including every thing that can be said upon the subject.
From the letters addressed to Sir Astley Cooper upon this subject, we shall venture now to extract a passage or two ; and the first that we shall notice is contained in one from Mr.
Chandler, of Canterbury. After observing that, in fifteen years, only two accidents of the kind under consideration had occurred, either in his practice or that of his coadjutor, Mr. Fletcher, but which two cases terminated favourably, he goes on to say, tc In accomplishing so desirable a point (that of saving the limb), the advantages obtained in a country hospital will, 1 apprehend, bear a greater proportion in the scale of success, than when the patient is placed in a crowded infirmary of a large manufacturing town, or in the metropolis: the constitution will, in general, be less impaired by excess, poverty, and other circumstances ; whilst purity of air in well-ventilated wards materially contributes towards recovery, even it the injury to the joint be extensive ; we consequently can be permitted to take greater latitude with our curative means upon an injured joint, relying on the powers of nature,, without being no. 2b8. " x 14S Critical Analysis, under the immediate necessity of anticipating the issue result-in<* from unfavourable habits, and in situations inimical to disease." (p. 281.) The next extract we are induced to make is from Mr.
Hammick's letter, dated from Plymouth, and which our author very truly designates an excellent letter. This gentleman begins by saying that many cases of compound dislocations have fallen under his care and observation, in the course of twentyfour years, and the result of his experience is, that there is not only a chance of saving the limb, but of its being at a future time useful.
He very minutely and satisfactorily describes his mode of proceeding where there is a probability of saving the limb, and then continues in these words:?" I have seen more than one case where, after great perseverance and risk, the limb has been saved, but, when the wounds were all healed, found to be of little or no use. As an example, a man who had had a compound dislocation of the ankle in the West Indies, from whence he was sent to England as an invalid, became my patient in this hospital, and, when received, (a period of thir-Having now reversed, 111 some measure, the arrangement of our author, by pointing out the discouraging circumstances that attend these accidents, and drawn the attention of the young surgeon to those points of the case that demand his peculiar consideration, an^l which he may be obliged to decide upon in a moment, we shall pursue our course, and describe the treatment of these accidents, being well assured that the vast importance of the subject does not render it necessary for us to apologize for having devoted so large a share of our attention to this discussion.
The mode of reducing the bones differs in no respect from that which has been described in treating of simple dislocations, and, when that is effected, a piece of lint dipped in the patient s blood forms the most natural covering to the wound. A manytailed bandage, the portions of which should not be sewn together, is then applied: by this plan, any one piece that becomes stiff may be renewed without disturbing the limb. T his bandage should always be kept wet with spirits of wine and water.
In the inward dislocation, the limb should rest upon its outer side, having on that side a hollow splint applied, with a foot-piece, at right angles; but, in the outward dislocation, it is best to place the limb on the heel, with a splint and lootpiece on each side, and with an aperture in the splint opposite to the wound. In each case the knee should be slightly bent, and great care must be taken to keep the foot at right angles withthe leg. The patient should lie on a mattress, and a pillow should extend half-way above the knee, and another rolled under the hip, to support the upper part of the thigh-bone.
The constitutional treatment next becomes a matter of consideration, the necessity for which depends, of course, upon the state and habit of the patient; but, with regard to purgatives, extremity; a practice which Sir Astley Cooper considers may occasionally be adviseable, but on which he remarks, " It is not my intention, however, to advocate either mode of treatment to the exclusion of the other, but to state the reasons which may be justly assigned for the occasional adoption of either." (p. 302.) Our opinion is certainly, upon the whole, favourable to this practice, in conformity with the following reasons which Sir Astley has stated :?1st, it removes the difficulty in reduction ; 2dly, if the bone be broken obliquely, by removing the point, it rests without difficulty upon the astragalus ; 3dly, it diminishes the spasmodic contractions of the muscles; 4thly, it renders the ulcerative process much less tedious; and, consequently, 5thly, the constitutional irritation is much lessened. These are the principal, but not the whole of the arguments adduced in favour of removing the extremity of the fractured bone, and against which only two objections have been urged: one is, that the limb becomes somewhat shorter, but which our author does not consider of great weight, and we agree with him entirely; and the-other consideration is, that the joint becomes necessarily anchylosed, the truth of ?which is very doubtful; and, indeed, Sir Astley mentions two cases in which this did not happen : and, even if it should, the motion of the tarsal bones becomes so much increased as to be a substitute for that of the ankle. ?while many writers mention the immoderate exhibition of purgatives, emetics, and mercurials ; but the author before us holds that these have been placed in the first rank precisely by those physicians "who regard the abdomen as the seat of the disease," and, of course, thinks they merit but little notice.
M. Falret then proceeds to a regular analysis of the moral affections incidentally mentioned by M. Villermay as causing hypochondriasis, by which the extent of their influence is unequivocally demonstrated; forty examples of disease from causes purely moral being detailed in a work intended to advocate an opposite opinion. It is, however, but just towards M. viscera which have been regarded as primarily affected return to their natural state? How can it be maintained that an organ, derangemeut in the functions of which are indispensably necessary to characterize the disease, are yet not the seat of such disease? I might as well be told, that the spontaneous luxation of the femur (morbus coxarum) resides in the knee, because the pain is often more severe there than in the coxo-femoral articulation. Why, then, have not the phenomena referrible to the head attracted all the attention of medical men ? " I shall here content myself with mentioning two of the principal causes of error in the diagnosis of hypochondriasis: 1st, the opinion of the seat of the passions being in the abdomen ; 2d, the habit, long prevalent among physicians, of regarding the brain as only secondarily affected.
" Does the tongue become yellow, the epigastric region paiuful, or are nausea or vomiting excited, uutler the influence of an intellectual or moral cause, immediately some exclaim, there is gastric derangement, and others gastric irritation, or even gastritis. But why refuse to take into consideration the nature of the cause ? why not give their just value to the concomitant phenomena,?such as the head-ach, a certain torpor of ideas, (if I may thus express myself,) the insomnolence, the starting awake, the disorder of the cerebral circulation, the irregularity of the animal heat, the constraint of the voluntary motions? I believe, in the existence of gastritis, when the cerebral symptoms having ceased, the disorder of the stomach continues, or increases in degree; but, in the opposite case, is it reasonable not to admit the cerebral irritation as the cause, and the irritation of the stomach as the effect? Ought the diagnosis to be taken from symptoms of small importance and of ephemeral duration, which are often wanting, while the nature of the disease rests always the same] This, however, has been done with regard to hypochondriasis." (p. 402?5.) Symptoms.?Physicians, entertaining a different opinion regarding the seat of the complaint, having also given a different history of the symptoms; M. Villermay and others asserting that disorder of the digestive functions mark the first stages, and that the extension of the disease to the organs of the chest constitutes the second; the third being marked by the lesion of the organs of animal life. i? Soon (we translate the words of M. Villermay,) the organs of our external relations, or which place us in relation with all which surrounds us, participate iu the trouble of the sensitive or interior life." This description M. Falret confidently pronounces to be derived from other sources than actual observation; and, according to this author, the train of symptoms is in reality directly the reverse of what is stated in the most esteemed works. He enumerates shortly the phenomena attending the senses, from which it appears that the sight, hearing, smell, and taste, are subject to painful or depraved affections, and sometimes endowed with a morbid state of sensibility: this is particularly the rase with regard to the touch,?the slightest degree either ofc heat or cold producing strong impressions. There is occasionally an approach to syncope; during which, however, the patient does not entirely lose his consciousness, and from which he speedity recovers. Pain in the head is likewise a general occurrence, which varies in situation and in degree : in some the integuments become preternaturally tender, and the patient even complains of exquisite pain in the hair.
vve come now to the mental functions. The intellect does not, in general, suffer much at the commencement, and sometimes it even appears more vivid than usual, though this does not last long. The memory becomes impaired, and the judgment slow, but sound, " except in what regards the health." " The imagination is very active, and very mobile: in the last stage of ltypochondriasis, the disorder of the intellect often constitutes true mental alienation." The whims and fantasies of hypochondriacs are very numerous, and many of them such as to provoke a smile, even when we pity the subject of such strange delusions. M. Falret mentions, as not uncommon, the idea of a detonation, which they compare to the discharge of a piece of fire-arms, taking place in the head, breast, or belly; while others imagine that they feel the movements of some living creature in one or more parts of the body. Our author knew a lady who, when she looked at her skin, thought it seal}' like that of a carp, but she could immediately rectify this false impression by the sense of touch. To these instances mentioned by M. Falret, we may add a few taken from other sources.? " Greding gives an account of a medical practitioner who applied to him for assistance, under an impression that his stomach was filled with frogs, which had been successively spawning ever since he had bathed, when a boy, in a pool, in whxh he perceived a few tadpoles. He had spent his life in trying to expel this imaginary evil, and had travelled to numerous places to consult the first physicians of the day upon his obstinate malady. It was in vain to attempt convincing him that the gurglings, or borborygmi, he heard, were from extricated and erratic wind. He argued himself, says M. Greding, into a great passion in my presence, and then asked me if I did not hear the frogs croak."* The learned writer from whom we have taken the above quotation likewise informs us, that Marcellus Donatus mentions a baker of Ferara, who imagined himself a lump of butter, and durst not sit in the sun or near a fire, for fear of being melted. Zimmerman met with a case where a man fancied himself a barley-corn, and did not venture to go out, lest he should be picked up by some bird. * Good's Sludy of Medicine,vol. iii. p. 147. 254 Critical Analysis, And it occurred to ourselves to know of a gentleman who sup-i posed bis " nether bulk" to be made of glass, and who never sat down without much caution. M. Villermay mentions a hypochondriac who had set apart one of his rooms for his chamber-pots, of which he had made a very numerous collection filled with urine. He made use of a new one every day, and frequently passed them all in review, forming a kind of museum new in the history of natural curiosities.
One of the most annoying absurdities among the symptoms of hypochondriasis is the degree of vacillation in every purpose, and the deliberation which frequently precedes the most trivial actions. Dr. Reid, in his amusing work upon Nervous Diseases, mentions that he called upon a young gentleman at Oxford, who had injured his health by severe application. It was afternoon, and his friend was still in bed, not having been able to determine whether he should put on his smallclothes or a pair of pantaloons. Having pursued his ratiocination for some time longer, the important decision was made in favour of the latter; but he had not been dressed many minutes before he repented of his choice, and during the rest of the day he wore breeches.
We once lodged at the house of a worthy old lady, who, though rather infirm, frequently took the trouble of climbing up stairs to request our opinion whether she ought to rest herself by sitting 01* reclining on her sofa. From these and similar instances we recognize the fidelity of the picture of an hypochondriac as given by Moliere, in his <? Malade Imaginaire," when he makes M. Argan say, " Monsieur